HomeMy WebLinkAboutMiscellaneous - 562 SALEM STREET 4/30/2018 (2) 562 SALEM STREET
210/038.0-0102-0000.0
1
Date .( ` 5. . . .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . . . . �7 . . . . . . ... . . . . . . . .
has permission to perform . / e '"!Q�� . .
wiring in the building of rFJ e-
at . . . .�3o.,, . !v)S—,(: . . . . . . . . . . . .NoA Andover, Mass.
Fee�)J=-. . . Lic. No. '�� . . M� . . . . . . .
ELECT ICAL INSPECTOR
Check
1 ) 338
P-N Commonwealth of Massachusetts Official Use Only IN
Department of Fire Services Permit No. 1 13
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /l�f13
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) s(,Z
Owner or Tenant (y ,�C,C ®�,RN� Telephone No.
Owner's Address 5.- i„e-
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Ae,0 Amps / /Zia Volts Overhead Er Undgrd❑ No.of Meters /
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: q ��7� �kt6 d Sf Dr%!/�
A
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ - ❑ o.of Emergency Lighting
rnd grnd. Batte Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones
No.of Switches No.of Gas Burners No.o Detection and
-Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number. Tons KW......... No.ofSelf-Contained
Totals: Detection/Alertina Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW ecurity Systems.*
Ballasts No.of Devices or Equivalent
No.of Water No.
KW No,o aof sts Data Wiring:
Si ns BalNo.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications irm :
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: /OZJ (When required by municipal policy.)
Work to Start: // 1/3 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE /BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: �j=� D/1,�1 1 ec7�64r�7R LIC.NO.: x¢/70 7
Licensee: e<T� gyp ��S Signature LIC.NO.: 41707-1
(If applicable,enter "exempt"in the license number line)
Bus.Tel.No. /7f�. �SCr-o'?3s
Address: c �2 4,U :
, iyz3 Alt.Tel.No.: 928 ZGSz�Z�%
*Per MG.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)[Iowner El owner's a ent.
Owner/Agent 7
Signature Telephone No. PERMIT FEE. $
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
h ,Y www mass.gov/Zia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information J / Please Print Legibly
Name (Business/Organization/Individual): �1�. �1ei TD/Z2/3 �`�`7 �✓� l �-7'771�c_7�/Z
Address:-
City/State/Zip: �,44 c,e ' ,44 63/94 3 Phone#: 17e5 •—7 S--e) --0 73Z
Are you an employer?Check the appropriate box: Type of project(required):
❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
al am a sole proprietor or partner- listed on the attached sheet.t ? ❑Remodeling
hip and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]uit employees.[No workers'
q ] 131-1 Other
comp.insurance required.]
my applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.poli6y information.
tin an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
formation.
surance Company Name:
dicy#or Self-ins.Lid.#: Expiration Date:
b Site Address: City/State/Zip:
:tach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Le up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
✓estigations of the DIA for insurance coverage verification.
'o hereby certify
�under thepains andpenalties ofperjury that the information provided above is trite and correct.
>nature 1 -�CA_ � Date:
one#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
�l
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permithicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 ext 406 or. 1-877-MASSAFE
vised 5-26-05 Fax#617-727-7749
n
Location .514 L/=ill 5 j
Nt. `� Date J/, Z
NORTh TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
` 011w; new
Building/Frame Permit Fee $
sI
o •
Foundation Permit Fee $
SACNUSE
Oermit Fee $
�\/, wer.Connection Fee $
K
t;r ��y Water Connection Fee $
AV
No. Andover Cour Building Inspector
Div. Public Works
PERJiIT NO. Z T APPLICATION FOR PEI ,f ABUILD - NORTH ANDOVER, MASS. PAGE 1
MAS $VO. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK PAGE
ZONE I SUB DIV. LOT NO.
_ r-
LOCATION PURPOSE OF BUILDING
�'� C6v&/.'vwe7s SC/DE - t/J /=
OWNER'S NAME 0 ,7-1 tY 13 d tlRw, — NO. OF STORIES SIZE
OWNER'S ADDRESS / ^/ ', C, % BASEMENT OR SLAB --
ARCHITECT'S NAME (� aC SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME /2�M rT,Lr ®�5.,�,� SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES-SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION /I MATERIAL OF CHIMNEY
IS BUILDING ALTERATION V IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM REQ IIREMENTS OF CODE r,�f}� IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY A {� L. IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST
PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
Z SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED'BY BUILDING INSPECTOR
DATE FILED
BOARD OF HEALTH
SIGNATOR OF OWN OR AUTH RIZED T
OWNER TEL.#
FEE i COO
NTR.LIC.# '
PLANNING BOARD
PERMIT GRANTED �y
� 19/
BOARD OF SELECTMEN
BUILDING SP R
BUILDING RECORD
1 OCCUPANCY 12 ;
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION —I 8 INTERIOR FINISH
CONCRETE B 1 2 13
CONCRETE BL'K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER _ ——
DRY WALL
UNFIN.
3 BASEMENT 11
AREA FULL FIN. B'M'TAREA _
1/1 1/2 1/1 FIN. ATTIC AREA _
NO BM T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW'D _
ASBESTOS SIDING _ COMNICN
VERT. SIDING ASPH.TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STIRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BILK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR POOR _
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH )3 FIX.)
GAMBREL MANSARD TOILET RM. 12 FIX.) _
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK _
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING I 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
011
B'M'T 2nd _ ELECTRIC
1st 13rd I NO HEATING
���.:...,l�.,..___� -_ _ . .�,..a•. _ S h��.�.:'iA-:.:Awa.7.:a:�wvi.w�rw,z�c..a-.^_....�.t::,�wi.e�cr
r- COMMONWEALTH 1DEPARTMENT OF PUBLIC SAFETY
�~ OF ' '1010 COMMONWEALTH AVE.
�� MASSACHUSETTS BOSTON,MASS.02215
LICENSE
EXPIRATION DATE CONSTR. SUPERVISOR
06/30/1993
I RESTRICTIONS EFFECTIVE DATE LIC-NO. Fi
NONE _ 06/30/1991 017853
f R
STEPHEN R COTE
3 DELVINE - TER
-S # 017-24-6891 HAVERHILL .MA 01830 P ,'
I PHOTO( I,A,4LNG OPR ONLY) FEE: " z;
100.00 E
NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY
--. HEIGHT:
STAMPED OR -SIGNATURE OF THE COMMISSIONER
---" DOB:
06/24/1931 G 0
THIS DOCUMENT MUST B
SIGNATURE OF LICENSEE
CARRIED ON THE PERSON OI
THE HOLDER WHEN ENGAG
I OTHF �II` PRINT ED IN THIS OCCUPATION COMMISSIONEoopR
f'L.MIVr. 151riw vu. 06 amIri su % ,NORTH %0W11%4L;n VA i 1UN FIN p
^�O 1V M
own of
No. O
IRIVEWAY ENTRY - K M 19?
PERMIT MEer,rt ass
OR pR
SSq
BOARD OF HEALTH
PERMI LD
tea ....
THIS CERTIFIES T T.... ..... . .................................. ...................... •
BUILDING INSPECTOR
has permission to erect . . . bepbuildings on ............ . ...................... Rough
ICA& � MMU
� ��•,r,�O....... Chimney
to be occupied ............
.....
Final
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in
PLUMBING INSPECTOR
this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough
Buildings in the Town of North Andover.
Final
VIOLATION of the Zoning or Building Regulations Voidser 't.
PERMIT EXPIRES 6 ONTHS ELECTRICAL INSPECTOR
Rough
UNLESS CON RUC T Service
Final
BUILDING INSPECTOR GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Final
Display in a Conspicuous Place on the Premises
FIRE DEPT.
Do Not Remove Burner
No Lathing to Be Done Until Inspected and Approved by Smoke Det.
Building Inspector